Abstract
Abstract: The goal of the Veterans Health Study (VHS) was to extend the work of the Medical Outcomes Study (MOS) into the VA, by developing methodology for monitoring patient-based outcomes of care for use in ambulatory outpatient care. The principal objective of the VHS was developing valid and reliable measures to assess general health-related quality of life (HRQoL) and identifying the presence of selected health conditions, their severity, and their impact on HRQoL. In this article, we provide an overview of the historical context, framework, objectives, and applications of the VHS for the purpose of assessing the health outcomes of veteran patients. The VHS is a prospective observational study that has followed 2425 VA patients for up to 2 years. The patients were sampled from users of the Veterans Affairs (VA) ambulatory care system in the Boston area. The health conditions selected were hypertension, diabetes, chronic lung disease, osteoarthritis of the knee, chronic low-back pain, and alcohol-related problems. These conditions were chosen because they are both prevalent in the VA and have measurable impacts on HRQoL. One of the cornerstones of the VHS was the development of the Veterans SF-36, modified from the MOS SF-36 for use in veteran ambulatory populations. Other key accomplishments included the development of patient-based disease-specific measures of health and the establishment of methods and logistics for comprehensive health outcomes research in large health care systems such as the VA, using these patient-based measures. Selected measures developed in the VHS, eg, the Veterans SF-36, have been integrated into the VA outcomes measurement system. The scope of the VHS is unique; it resulted in the development of a broad range of patient-focused process and outcome measures, as well as methodologies for assessing large numbers of patients, that have been widely used in the VA outpatient health care system for monitoring health outcomes across the nation.
WE LIVE in an era of major changes in the health care system, where clinicians, administrators, policymakers, and consumers all agree that monitoring patients, health is critically important (Ellwood, 1988; Gilbody et al., 2002; Slade, 2002). The health care system is increasingly held accountable for the services it renders, with the ultimate goal being to reduce costs while maintaining quality of care and improving patient outcomes. To meet the challenges of increased competition and accountability, innovative approaches have been developed for assessing the patient's health and for monitoring the impact of health care on patients' health (Epstein, 1995; Kassirer, 1995).
In recent years, new patient-centered approaches have been developed that offer reliable and valid measures for assessing the health of patients (Greenfield & Nelson, 1992; Patrick & Erikson, 1993). These measures often are based on patient's perceptions of disease, illness, and health. Using measures such as these, the Veterans Health Administration (VHA), the nation's largest integrated health care system, has placed major emphasis on the development of health status monitoring systems for the purposes of evaluating the health of veterans who use the veterans administration (VA) health care system (Kizer, 1997; "The VA," 1993).
The VA has long been concerned with health services planning on a massive scale. The efficiency and effectiveness of health services that the VA provides are increasingly subject to careful scrutiny by the US Congress, the public, and its consumers. Historically, the VA has been in a unique position to develop systems for evaluating health quality and outcomes, given a higher level of federal oversight and public visibility than other health care systems. National policy makers want to know how the VA compares with other systems of care, with respect to the health burden of its client population, the costs of its services, and the outcomes of its care (Randall et al., 1987). Typically, VA patients present with greater and more complex health problems than do other populations of health care users with nominally the same health conditions (Wolinsky et al., 1985). Comparisons of health outcomes within and outside of the VA are important markers of performance and patient-care. Issues of provision of patient care at competitive costs are central to future resource allocation decisions facing the VA. The VA health care system thus provides an environment and means to test the application of patient-centered measures within an integrated system of care.
One of the goals of providing health care to the users of the VA is to improve the quality of life for veterans. As the VA population ages, and as the percentage of veterans with chronic illnesses grows, the VA has been shifting increasingly to long-term ambulatory and community-oriented care. Adoption of health outcomes methodology has been germane to VA ambulatory care, because such assessments are based in part upon patient-perceived health-related quality of life (HRQoL) outcomes. This technology of patient-based experience will enlarge our understanding of patients' perceived needs beyond current assessments of their disease status, and serve as a broader, more comprehensive approach to measure patient-based outcomes of care.